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Trikudanathan G, Yazici C, Evans Phillips A, Forsmark CE. Diagnosis and Management of Acute Pancreatitis. Gastroenterology 2024; 167:673-688. [PMID: 38759844 DOI: 10.1053/j.gastro.2024.02.052] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 01/03/2024] [Accepted: 02/18/2024] [Indexed: 05/19/2024]
Abstract
Acute pancreatitis (AP) is increasing in incidence across the world, and in all age groups. Major changes in management have occurred in the last decade. Avoiding total parenteral nutrition and prophylactic antibiotics, avoiding overly aggressive fluid resuscitation, initiating early feeding, avoiding endoscopic retrograde cholangiopancreatography in the absence of concomitant cholangitis, same-admission cholecystectomy, and minimally invasive approaches to infected necrosis should now be standard of care. Increasing recognition of the risk of recurrence of AP, and progression to chronic pancreatitis, along with the unexpectedly high risk of diabetes and exocrine insufficiency after AP is the subject of large ongoing studies. In this review, we provide an update on important changes in management for this increasingly common disease.
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Affiliation(s)
- Guru Trikudanathan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota
| | - Cemal Yazici
- Division of Gastroenterology and Hepatology, University of Illinois, Chicago, Illinois
| | - Anna Evans Phillips
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida.
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Tenner S, Vege SS, Sheth SG, Sauer B, Yang A, Conwell DL, Yadlapati RH, Gardner TB. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol 2024; 119:419-437. [PMID: 38857482 DOI: 10.14309/ajg.0000000000002645] [Citation(s) in RCA: 60] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 12/08/2023] [Indexed: 06/12/2024]
Abstract
Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.
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Affiliation(s)
- Scott Tenner
- State University of New York, Health Sciences Center, Brooklyn, New York, USA
| | | | - Sunil G Sheth
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Bryan Sauer
- University of Virginia, Charlottesville, Virginia, USA
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3
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Yang AL, Vege SS. Fluid resuscitation in acute pancreatitis. Curr Opin Gastroenterol 2023:00001574-990000000-00086. [PMID: 37421393 DOI: 10.1097/mog.0000000000000959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW The purpose of the review is to critically evaluate the evidence from the literature to establish the current perspective on fluid resuscitation (FR) in acute pancreatitis (AP). We will review the rationale, type of fluid, rate of administration, total volume, duration, monitoring, ideal outcomes to be studied in clinical trials and recommendations for future studies. RECENT FINDINGS FR remains the key component of supportive therapy in AP. The paradigm has shifted from administration of aggressive fluid resuscitation towards more moderate FR strategies. Lactated Ringer's remains the preferred fluid for resuscitation. There remain critical gaps in knowledge regarding the end point(s) to indicate adequate resuscitation, and accurate assessments of fluid sequestration and intravascular volume deficit in AP. SUMMARY There is insufficient evidence to state that goal-directed therapy, using any of the parameters to guide fluid administration, reduces the risk of persistent organ failure, infected pancreatic necrosis, or mortality in AP, as well as the most appropriate method for the same.
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Affiliation(s)
- Allison L Yang
- Division of Gastroenterology & Hepatology, Weill Cornell Medicine, New York, New York
| | - Santhi Swaroop Vege
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Crosignani A, Spina S, Marrazzo F, Cimbanassi S, Malbrain MLNG, Van Regenemortel N, Fumagalli R, Langer T. Intravenous fluid therapy in patients with severe acute pancreatitis admitted to the intensive care unit: a narrative review. Ann Intensive Care 2022; 12:98. [PMID: 36251136 PMCID: PMC9576837 DOI: 10.1186/s13613-022-01072-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/11/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with acute pancreatitis (AP) often require ICU admission, especially when signs of multiorgan failure are present, a condition that defines AP as severe. This disease is characterized by a massive pancreatic release of pro-inflammatory cytokines that causes a systemic inflammatory response syndrome and a profound intravascular fluid loss. This leads to a mixed hypovolemic and distributive shock and ultimately to multiorgan failure. Aggressive fluid resuscitation is traditionally considered the mainstay treatment of AP. In fact, all available guidelines underline the importance of fluid therapy, particularly in the first 24–48 h after disease onset. However, there is currently no consensus neither about the type, nor about the optimal fluid rate, total volume, or goal of fluid administration. In general, a starting fluid rate of 5–10 ml/kg/h of Ringer’s lactate solution for the first 24 h has been recommended. Fluid administration should be aggressive in the first hours, and continued only for the appropriate time frame, being usually discontinued, or significantly reduced after the first 24–48 h after admission. Close clinical and hemodynamic monitoring along with the definition of clear resuscitation goals are fundamental. Generally accepted targets are urinary output, reversal of tachycardia and hypotension, and improvement of laboratory markers. However, the usefulness of different endpoints to guide fluid therapy is highly debated. The importance of close monitoring of fluid infusion and balance is acknowledged by most available guidelines to avoid the deleterious effect of fluid overload. Fluid therapy should be carefully tailored in patients with severe AP, as for other conditions frequently managed in the ICU requiring large fluid amounts, such as septic shock and burn injury. A combination of both noninvasive clinical and invasive hemodynamic parameters, and laboratory markers should guide clinicians in the early phase of severe AP to meet organ perfusion requirements with the proper administration of fluids while avoiding fluid overload. In this narrative review the most recent evidence about fluid therapy in severe AP is discussed and an operative algorithm for fluid administration based on an individualized approach is proposed.
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Affiliation(s)
- Andrea Crosignani
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Spina
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Marrazzo
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Manu L N G Malbrain
- First Department of Anaesthesia and Intensive Therapy, Medical University of Lublin, Lublin, Poland.,International Fluid Academy, Lovenjoel, Belgium
| | - Niels Van Regenemortel
- Department of Intensive Care Medicine, Antwerp University Hospital, Antwerp, Belgium.,Department of Intensive Care Medicine, Ziekenhuis Netwerk Antwerpen Campus Stuivenberg, Antwerp, Belgium
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Thomas Langer
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy. .,Department of Anaesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
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Kwiatek-Średzińska K, Kiryłowska M, Uścinowicz M, Daniluk U, Lebensztejn D. The course of acute pancreatitis in children and potential simple laboratory markers of severity - a single centre retrospective study. Acta Paediatr 2022; 111:2229-2234. [PMID: 35960175 DOI: 10.1111/apa.16514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 07/10/2022] [Accepted: 08/11/2022] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the usefulness of routinely measured biochemical and complete blood count parameters as potential markers of the severity of pediatric acute pancreatitis. METHODS The retrospective study included children with acute pancreatitis hospitalised over a 3-year period. Demographic, clinical and laboratory data were collected. RESULTS 55 patients were enrolled in the study. Mild acute pancreatitis was diagnosed in 45 children (82%), moderately severe in 7 (13%), and severe in 3 patients (5%). Together 10 children (18%) were categorized into a single severe group. Children with severe acute pancreatitis had higher white blood cell and platelet counts on admission as well as a C-reactive protein concentration after 48 hours. The C-reactive protein concentration after 48 hours (cut-off: 127,2 mg/l) and the white blood cell count on admission (cut-off: 13,5x103 /μl) were found to be statistically significant markers in predicting the severity of the disease. The C-reactive protein concentration after 48 hours was demonstrated as an independent predictor. CONCLUSION Severe acute pancreatitis is observed in a quite significant percentage of children. The white blood cell count on admission and the C-reactive protein concentration after 48 hours (as an independent predictor) may be potential simple laboratory markers of the severity of the disease.
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Affiliation(s)
- Kamila Kwiatek-Średzińska
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Martyna Kiryłowska
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Mirosława Uścinowicz
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Urszula Daniluk
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Dariusz Lebensztejn
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
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Vogel M, Ehlken H, Kluge S, Roesch T, Lohse AW, Huber S, Sterneck M, Huebener P. High risk of complications and acute-on-chronic liver failure in cirrhosis patients with acute pancreatitis. Eur J Intern Med 2022; 102:54-62. [PMID: 35672219 DOI: 10.1016/j.ejim.2022.05.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/18/2022] [Accepted: 05/27/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND & AIMS Acute pancreatitis (AP) is a frequent indication for hospitalization and may present with varying degrees of severity. AP often coincides with hepatic disease, yet the impact of liver cirrhosis (LC) on the course of AP is uncertain, and early identification of patients at risk for complications remains challenging. We aimed to assess the impact of LC on the development of pancreatic and extra-pancreatic complications of AP, and to identify predictors of adverse outcomes in cirrhotic patients. METHODS All adult patients with LC and AP (LC-AP, n = 52) admitted to our institution between 01/2011-03/2020 were subjected to a 1:2 matched-pair analysis with patients with AP but without LC (NLC-AP, n = 104). RESULTS At hospital admission, Glasgow-Imrie and Ranson scores as well as markers of systemic inflammation were comparable in LC-AP and NLC-AP patients, and both groups had similar rates of necrotizing AP. Infectious complications were more prevalent, and medical interventions were performed more often and with higher complication rates in LC-AP patients. While only 12.5% of NLC-AP patients developed organ failures, 48% of LC-AP patients developed single (7.7%) or multiple organ failure (40.4%), resulting in 44% of LC-AP patients with acute-on-chronic liver failure (ACLF). Patients with overt portal hypertension were particularly prone for decompensation. Mortality was higher among LC-AP compared to NLC-AP patients (6-month mortality 25% vs. 1.9%, p < 0.001), and SOFA and MELD scores at admission most accurately predicted outcomes in LC-AP. CONCLUSION Among AP patients, concomitant cirrhosis substantially increases the risk for infections, periprocedural complications, multiorgan failure and death.
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Affiliation(s)
- Michael Vogel
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Ehlken
- Department for Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Roesch
- Department for Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samuel Huber
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Huebener
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Fauzi A, Suhendro, Simadibrata M, Rani AA, Sajuthi D, Permanawati, Amanda R, Makmun D. Role of glycodeoxycholic acid to induce acute pancreatitis in Macaca nemestrina. J Med Primatol 2022; 51:134-142. [PMID: 35306662 PMCID: PMC9310849 DOI: 10.1111/jmp.12577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/04/2022] [Accepted: 02/26/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute pancreatitis exhibits a rapid clinical progression which makes it difficult to observe in human; hence, an experimental animal model is needed. This preliminary study performed an induction of acute pancreatitis using glycodeoxycholic acid (GDOC) in an experimental macaque model. METHODS GDOC injections (initial dose of 11.20 mg/kg) were administered in an escalating manner at specific time points. The injection was given along the bilio-pancreatic duct, followed by measurement of vital signs, serum amylase-lipase, TNF-α, procalcitonin, oxidative stress parameters, and microscopic and macroscopic findings. RESULTS The results indicated that acute pancreatitis occurred following induction with low-dose GDOC. Serum amylase and lipase levels increased with subsequent GDOC injections. Blood pressure and heart rate were elevated, indicating abdominal pain. Changes in TNF-α, procalcitonin, and oxidative stress values showed active inflammation. We observed histologic features of pancreatitis and as the dose increased, vasodilation of the splanchnic vasculatures was observed. CONCLUSIONS Small dose GDOC injection in the bilio-pancreatic duct may have a role to induce acute pancreatitis in Macaca nemestrina.
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Affiliation(s)
- Achmad Fauzi
- Gastroenterology‐pancreatobiliarry and GI Endoscopy DivisionDepartment of Internal MedicineFaculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo HospitalJakartaIndonesia
| | - Suhendro
- Tropical medicine Division Department of Internal MedicineFaculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo HospitalJakartaIndonesia
| | - Marcellus Simadibrata
- Gastroenterology‐pancreatobiliarry and GI Endoscopy DivisionDepartment of Internal MedicineFaculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo HospitalJakartaIndonesia
| | - Abdul Azis Rani
- Gastroenterology‐pancreatobiliarry and GI Endoscopy DivisionDepartment of Internal MedicineFaculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo HospitalJakartaIndonesia
| | - Dondin Sajuthi
- Primate Research CentreInstitut Pertanian BogorBogorIndonesia
| | - Permanawati
- Primate Research CentreInstitut Pertanian BogorBogorIndonesia
| | - Rosvitha Amanda
- Gastroenterology‐pancreatobiliarry and GI Endoscopy DivisionDepartment of Internal MedicineFaculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo HospitalJakartaIndonesia
| | - Dadang Makmun
- Gastroenterology‐pancreatobiliarry and GI Endoscopy DivisionDepartment of Internal MedicineFaculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo HospitalJakartaIndonesia
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Liao J, Zhan Y, Wu H, Yao Z, Peng X, Lai J. Effect of aggressive versus conservative hydration for early phase of acute pancreatitis in adult patients: A meta-analysis of 3,127 cases. Pancreatology 2022; 22:226-234. [PMID: 35031209 DOI: 10.1016/j.pan.2022.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/30/2021] [Accepted: 01/02/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The advantages of aggressive hydration compared to conservative hydration within 24 h for acute pancreatitis (AP) remain controversial in adult patients. A meta-analysis was undertaken to investigate whether aggressive strategies are more beneficial. METHODS We searched (on February 1, 2021) PubMed, Embase, and the Cochrane Library for eligible trials that assessed the two therapies and performed a meta-analysis. The primary endpoint was in-hospital mortality. Secondary outcomes were adverse events (e.g., renal failure and pancreatic necrosis) within 24 h of treatment. RESULTS Five randomized controlled trials and 8 observational trials involving 3127 patients were identified. Patients with severe pancreatitis showed significant difference of in-hospital mortality (OR 1.75; 95% CI 1.32-2.33) in aggressive hydration group, which were less susceptible to study type and age. Patients with severe pancreatitis were likely to develop respiratory failure (OR 5.08; 95% CI 2.31-11.15), persistent SIRS (OR 2.83; 95% CI 1.58-5.04), renal failure (OR 2.58; 95% CI 1.90-3.50) with significant difference. A longer hospital stay was observed in patients with severe pancreatitis (WMD 7.61; 95% CI 5.51-9.71; P < 0.05) in the aggressive hydration group. Higher incidence of pancreatic necrosis (OR 2.34; 95% CI 1.60-3.42; P < 0.05) was major susceptible to observational studies, old patients and mild pancreatitis. CONCLUSIONS Compared to conservative hydration, aggressive hydration increases in-hospital mortality and the incidence of renal failure, pancreatic necrosis with relatively strong evidence. Further investigation should be designed with a definitive follow-up period and therapeutic goals to address reverse causation bias.
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Affiliation(s)
- Jiyang Liao
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Yang Zhan
- The Acupuncture Rehabilitation Clinical College of Guangzhou University of Chinese Medicine, No. 12 Airport Road, Baiyun District, Guangzhou, 510000, Guangdong Province, China
| | - Huachu Wu
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Zhijun Yao
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Xian Peng
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China
| | - Jianbo Lai
- Department of Intensive Care Unit, Shenzhen Hospital of Integrated Traditional Chinese and Western Medicine, No. 3 Shajing Street, Baoan District, Shenzhen, 518000, Guangdong Province, China.
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The prognostic value of serum and urine amylase levels and blood count parameters in assessing the risk of post-endoscopic pancreatitis development. GASTROENTEROLOGY REVIEW 2021; 16:132-135. [PMID: 34276840 PMCID: PMC8275959 DOI: 10.5114/pg.2021.106664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/30/2020] [Indexed: 11/17/2022]
Abstract
Introduction Detection of post-endoscopic pancreatitis (PEP) in the first hours after endoscopic retrograde cholangiopancreatography (ERCP) can limit its consequences, while excluding it can provide safe discharge of the patient. Therefore, a simple, clinically available test is needed for this purpose. Aim The assessment of the risk of PEP development based on serum and urine amylase levels and parameters included in blood counts 4 h after ERCP. Material and methods The study included 398 patients after therapeutic ERCP. Four hours after the procedure was completed, serum and urine amylase levels and blood count parameters were analysed. Results The optimal serum amylase level for PEP detection was 516 UI/l, with ACC = 0.94, sens. 77.8%, spec. 0.95; positive predictive value (PPV) 0.412, negative predictive value (NPV) 0.98, positive likelihood factor (LR+) 14.93, and negative likelihood factor (LR-) 0.23. The serum amylase level for exclusion of PEP was 184 UI/l with ACC 0.79, sens. 0.83, spec. 0.79, PPV 0.16, NPV 0.99, and LR- 0.21. The optimal urine amylase level for detection and exclusion (based on Youden index) was 575 UI/l, sens. 83.33%, spec. 81.3%, PPV 0.172, NPV 0.99, LR+ 4.44, and LR- 0.20. Conclusions Serum amylase levels above 516 UI/l at 4 h after ERCP should be an indication for further observation in hospital, and levels below 184 UI/l may justify safe discharge of the patient. Additional determinations of urine amylase levels and parameters included in blood counts do not improve the diagnostic capacity for the detection or exclusion of PEP risk.
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10
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Zhang Y, Yu WQ, Zhang J, Fu SQ, Fu QH, Liang TB. Efficacy of Early Percutaneous Catheter Drainage in Acute Pancreatitis of Varying Severity Associated With Sterile Acute Inflammatory Pancreatic Fluid Collection. Pancreas 2020; 49:1246-1254. [PMID: 33003087 DOI: 10.1097/mpa.0000000000001666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the efficacy of early percutaneous catheter drainage (PCD) for sterile acute inflammatory pancreatic fluid collection (AIPFC) in acute pancreatitis (AP) of varying severity. METHODS Retrospective analyses were performed based on the presence of sterile AIPFC and different AP severities according to 2012 Revised Atlanta Classification. RESULTS Early PCD contributed to obvious decreases in operation rate (OR, P = 0.006), infection rate (IR, P = 0.020), and mortality (P = 0.009) in severe AP (SAP). In moderate SAP with sterile AIPFCs, however, early PCD was associated with increased OR (P = 0.009) and IR (P = 0.040). Subgroup analysis revealed that early PCD led to remarkable decreases in OR for patients with persistent organ failure (OF) within 3 days (P = 0.024 for single OF, P = 0.039 for multiple OF) and in mortality for patients with multiple OF (P = 0.041 for OF within 3 days and P = 0.055 for 3-14 days). Moreover, lower mortality was found in SAP patients with early PCD-induced infections than with spontaneous infections (P = 0.027). CONCLUSIONS Early PCD may improve the prognosis of SAP with drainable sterile AIPFCs by reducing the OR, IR, and mortality.
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Affiliation(s)
| | - Wen-Qiao Yu
- Department of Surgical Intensive Care Unit, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | | | - Shui-Qiao Fu
- Department of Surgical Intensive Care Unit, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qing-Hui Fu
- Department of Surgical Intensive Care Unit, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Leonard-Murali S, Lezotte J, Kalu R, Blyden DJ, Patton JH, Johnson JL, Gupta AH. Necrotizing pancreatitis: A review for the acute care surgeon. Am J Surg 2020; 221:927-934. [PMID: 32878690 DOI: 10.1016/j.amjsurg.2020.08.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 07/30/2020] [Accepted: 08/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Necrotizing pancreatitis is a common condition with high mortality; the acute care surgeon is frequently consulted for management recommendations. Furthermore, there has been substantial change in the timing, approach, and frequency of surgical intervention for this group of patients. METHODS In this article we summarize key clinical and research developments regarding necrotizing pancreatitis, including current recommendations for treatment of patients requiring intensive care and those with common complications. Articles from all years were considered to provide proper historical context, and most recent management recommendations are identified. RESULTS Epidemiology, diagnosis, treatment in the acute phase, and complications (both short-term and long-term) are discussed. Images of surgical interventions are included from our institutional experience. CONCLUSION Necrotizing pancreatitis management remains heavily based on clinical judgement, although technological advances and clinical trials have made decision making more straightforward.
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Affiliation(s)
- Shravan Leonard-Murali
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Jonathan Lezotte
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Richard Kalu
- Department of Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Dionne J Blyden
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Joe H Patton
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Jeffrey L Johnson
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
| | - Arielle H Gupta
- Department of Surgery, Division of Acute Care Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA.
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Abstract
Acute pancreatitis (AP) is one of the most prevalent gastrointestinal conditions necessitating inpatient care. In the United States, over 275,000 patients are hospitalized for management of AP, with an estimate that over $2.5 billion is spent annually in treatment, with incidence continuing to rise. AP is a highly inflammatory and catabolic state, putting all patients with the condition at risk of malnutrition. Numerous approaches to nutrition support in pancreatitis have been evaluated and remain controversial. In this narrative review, we aim to give an overview of indications for nutrition and approach to management of nutrition in severe and predicted severe AP based on currently available data.
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Affiliation(s)
- Meera Ramanathan
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Abdul Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Biberci Keskin E, İnce AT, Sümbül Gültepe B, Köker İH, Şentürk H. The relationship between serum histon levels and the severity of acute pancreatitis. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:807-810. [PMID: 31530525 DOI: 10.5152/tjg.2019.18592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND/AIMS Despite various scoring systems and imaging methods, it is hard to predict the severity and the course of acute pancreatitis (AP), thereby necessitating better and more reliable markers. Since inflammation plays a key role in the pathogenesis of AP, we sought to determine whether histone, which is a novel inflammatory marker, may play a role in the prediction of severity and prognosis. MATERIALS AND METHODS A total of 88 consecutive adult patients (>18 years) with a first AP episode were prospectively enrolled in the study. Severe AP was defined as having a revised Atlanta score >3 in the first 48 h after admission. Circulating histone 3 and 4 levels were measured using the enzyme-linked immunosorbent assay method. RESULTS Eighty-eight consecutive adult patients with a first episode of AP were divided into two groups according to severity, in which 56 (63.6%) were assigned to the mild AP group and 32 (36.4%) to the severe AP group. White blood cell, hemoglobin, creatinine, and aspartate aminotransferase levels were significantly higher in the severe AP group. However, there was no difference in serum histone levels between the groups, and there was no correlation between revised Atlanta score and serum histone levels either. CONCLUSION Serum histone levels did not significantly differ between the severe and mild AP groups. Therefore, these markers may not provide additional benefit for determining the severity of AP.
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Affiliation(s)
- Elmas Biberci Keskin
- Department of Gastroenterology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Ali Tüzün İnce
- Department of Gastroenterology, Bezmialem Vakif University Medical School, İstanbul, Turkey
| | - Bilge Sümbül Gültepe
- Department of Gastroenterology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey; Department of Microbiology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - İbrahim Hakkı Köker
- Department of Gastroenterology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
| | - Hakan Şentürk
- Department of Gastroenterology, Bezmialem Vakıf University School of Medicine, İstanbul, Turkey
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14
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Yamashita T, Horibe M, Sanui M, Sasaki M, Sawano H, Goto T, Ikeura T, Hamada T, Oda T, Yasuda H, Ogura Y, Miyazaki D, Hirose K, Kitamura K, Chiba N, Ozaki T, Koinuma T, Oshima T, Yamamoto T, Hirota M, Masuda Y, Tokuhira N, Kobayashi M, Saito S, Izai J, Lefor AK, Iwasaki E, Kanai T, Mayumi T. Large Volume Fluid Resuscitation for Severe Acute Pancreatitis is Associated With Reduced Mortality: A Multicenter Retrospective Study. J Clin Gastroenterol 2019; 53:385-391. [PMID: 29688917 DOI: 10.1097/mcg.0000000000001046] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although fluid resuscitation is critical in acute pancreatitis, the optimal fluid volume is unknown. The aim of this study is to evaluate the association between the volume of fluid administered and clinical outcomes in patients with severe acute pancreatitis (SAP). METHODS We conducted a multicenter retrospective study at 44 institutions in Japan. Inclusion criteria were age 18 years or older, and diagnosed with SAP from 2009 to 2013. Patients were stratified into 2 groups: administered fluid volume <6000 and ≥6000 mL in the first 24 hours. We evaluated the association between the 2 groups and clinical outcomes using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of pancreatic infection and the need for surgical intervention. RESULTS We analyzed 1097 patients, and the mean fluid volume administered was 5618±3018 mL (mean±SD), with 708 and 389 patients stratified into the fluid <6000 mL and fluid ≥6000 mL groups, respectively. Overall in-hospital mortality was 12.3%. The fluid ≥6000 mL group had significantly higher mortality than the fluid <6000 mL group (univariable analysis, 15.9% vs. 10.3%; P<0.05). In multivariable logistic regression analysis, administration of ≥6000 mL of fluid within the first 24 hours was significantly associated with reduced mortality (odds ratio, 0.58; P<0.05). No significant association was found between the administered fluid volume and pancreatic infection, or between the volume administered and the need for surgical intervention. CONCLUSIONS In patients with SAP, administration of a large fluid volume within the first 24 hours is associated with decreased mortality.
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Affiliation(s)
- Takahiro Yamashita
- Emergency Medical Center, Fukuyama City Hospital, Zao-cho, Fukuyama City
- Acute Care Medical Center, Hyogo Prefectural Kakogawa Medical Center, Kanno-cho, Kakogawa City, Hyogo
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Shinjuku-ku
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Musashidai, Fuchu City
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Amanumacho, Omiya-ku, Saitama
| | - Mitsuhito Sasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tsukiji, Chuo-ku
| | - Hirotaka Sawano
- Senri Critical Care Medical Center, Osaka Saiseikai Senri Hospital, Tsukumodai, Suita
| | - Takashi Goto
- Department of Anesthesiology and Intensive Care, Hiroshima City Hiroshima Citizens Hospital, Motomachi, Naka-ku, Hiroshima City, Hiroshima
| | - Tsukasa Ikeura
- The Third Department of Internal Medicine, Kansai Medical University, Shinmachi, Hirakata
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Hongo, Bunkyo-ku
| | - Takuya Oda
- Department of General Internal Medicine, Iizuka Hospital, Yoshiomachi, Iizuka-shi
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Japanese Red Cross Musashino Hospital, Kyounancho, Musashino City
| | - Yuki Ogura
- Department of Gastroenterology and Hepatology, Tokyo Metropolitan Tama Medical Center, Musashidai, Fuchu City
| | - Dai Miyazaki
- Advanced Emergency Medical and Critical Care Center, Japanese Red Cross Maebashi Hospital, Asahi-cho, Maebashi City, Gunma
| | - Kaoru Hirose
- Department of Emergency Medicine, Shonan Kamakura General Hospital, Okamoto, Kamakura City, Kanagawa
| | - Katsuya Kitamura
- Division of Gastroentelology, Department of Medicine, Showa University School of Medicine, Hatanodai, Shinagawa-ku
| | - Nobutaka Chiba
- Department of Emergency and Critical Care Medicine, Nihon University Hospital, Kanda-Surugadai, Chiyoda-ku
| | - Tetsu Ozaki
- Department of Acute care and General Medicine, Saiseikai Kumamoto Hospital, Chikami, minami-ku, Kumamoto city, Kumamoto
| | - Toshitaka Koinuma
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine
| | - Taku Oshima
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Inohana, Chuo-ku, Chiba City, Chiba
| | - Tomonori Yamamoto
- Department of Traumatology and Critical Care Medicine, Osaka City University, Asahimachi, Abenoku, Osaka City, Osaka
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Hospital, Seiryo-cho, Aoba-ku
| | - Yukiko Masuda
- Emergency and Critical Care Center, National Hospital Organization Nagasaki Medical Center, Kubara, Omura, Nagasaki
| | - Natsuko Tokuhira
- Division of Intensive Care Medicine, University Hospital, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Mioko Kobayashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Kotobashi, Sumida-ku
| | - Shinjiro Saito
- Intensive Care Unit, Department of Anesthesiology, Jikei University School of Medicine, Nishi-Shinbashi, Minato-ku, Tokyo
| | - Junko Izai
- Department of Surgery, Saka General Hospital, Nishiki-cho, Shiogama City, Miyagi
| | - Alan K Lefor
- Department of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Shinjuku-ku
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Shinanomachi, Shinjuku-ku
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Iseigaoka, Yahata Nishi, KitaKyushu, Fukuoka
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Abstract
Acute pancreatitis (AP) is a common clinical emergency disorder, and its morbidity is increasing gradually. Severe AP (SAP) often occurs with a sudden onset and high mortality. Microcirculation disturbance and hemodynamic abnormality is one of the main pathophysiologic mechanisms of SAP. Early fluid resuscitation is the cornerstone of therapy. However, at present, the fluid type, the amount of fluid resuscitation, and the rehydration rate are still in dispute. Early goal-directed fluid therapy as an important individualized liquid resuscitation strategy has great significance to improve the prognosis of SAP. This article reviews the pathophysiological mechanisms of microcirculation disturbance, the related dispute of liquid resuscitation therapy, and the application of early goal-directed treatment strategy.
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Affiliation(s)
- Ai-Ru Liu
- Department of Gastroenterology, the Second Hospital of Suzhou University, Suzhou 215004, Jiangsu Province, China
| | - Duan-Min Hu
- Department of Gastroenterology, the Second Hospital of Suzhou University, Suzhou 215004, Jiangsu Province, China
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Abstract
Acute pancreatitis is among the most common gastrointestinal disorders requiring hospitalization worldwide. Establishing the cause of acute pancreatitis ensures appropriate management and proper health care resource utilization. Causes of acute pancreatitis include biliary, alcohol use, hypertriglyceridemia, hypercalcemia, drug-induced, autoimmune, hereditary/genetic, and anatomic abnormalities. Fluid therapy remains the cornerstone of managing acute pancreatitis. This article provides a brief summary of current evidence-based practices in the diagnosis and management of uncomplicated acute pancreatitis.
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Lin K, Ofori E, Lin AN, Lin S, Lin T, Rasheed A, Vasudevan V, Reddy M. Hypothermia-Related Acute Pancreatitis. Case Rep Gastroenterol 2018; 12:217-223. [PMID: 29928186 PMCID: PMC6006605 DOI: 10.1159/000489296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/17/2018] [Indexed: 02/02/2023] Open
Abstract
Acute pancreatitis (AP) is an inflammatory disease presenting from mild localized inflammation to severe infected necrotic pancreatic tissue. In the literature, there are a few cases of hypothermia-induced AP. However, the association between hypothermia and AP is still a myth. Generally, mortality from acute pancreatitis is nearly 3-6%. Here, we present a 40-year-old chronic alcoholic female who presented with acute pancreatitis induced by transient hypothermia. A 40-year-old chronic alcoholic female was hypothermic at 81°F on arrival which was improved to 91.7°F with warming blanket and then around 97°F in 8 h. Laboratory tests including complete blood count, lipid panel, and comprehensive metabolic panels were within the normal limit. Serum alcohol level was 0.01, amylase 498, lipase 1,200, ammonia 26, serum carboxyhemoglobin level 2.4, and β-HCG was negative. The entire sepsis workup was negative. During rewarming period, she had one episode of witnessed generalized tonic-clonic seizure. It was followed by transient hypotension. Fluid challenge was successful with 2 L of normal saline. Sonogram (abdomen) showed fatty liver and trace ascites. CAT scan (abdomen and pelvis) showed evidence of acute pancreatitis without necrosis, peripancreatic abscess, pancreatic mass, or radiopaque gallstones. The patient was managed medically and later discharged from the hospital on the 4th day as she tolerated a normal low-fat diet. In our patient, transient hypothermia from chronic alcohol abuse and her social circumstances might predispose to microcirculatory disturbance resulting in acute pancreatitis. Early and aggressive fluid resuscitation prevents complications.
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Affiliation(s)
- Kyawzaw Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Emmanuel Ofori
- GI Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Aung Naing Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Sithu Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Thinzar Lin
- Department of Internal Medicine, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Ameer Rasheed
- MICU, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Viswanath Vasudevan
- Critical Care Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
| | - Madhavi Reddy
- GI Department, The Brooklyn Hospital Center, Affiliate of the Mount Sinai Hospital, Brooklyn, New York, USA
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18
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Braha J, Tenner S. Fluid Collections and Pseudocysts as a Complication of Acute Pancreatitis. Gastrointest Endosc Clin N Am 2018. [PMID: 29519326 DOI: 10.1016/j.giec.2017.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Pseudocysts evolve from fluid collections and/or disruptions of the pancreatic duct. They may occur secondary to acute pancreatitis, pancreatic trauma, or chronic pancreatitis. Lacking the clinical information, radiologists may inappropriately call a fluid collection or any cystic lesion a pseudocyst. With no clear history of acute pancreatitis or chronic pancreatitis, this is rare. Complications include infection, intracystic hemorrhage, or rupture. Pseudocysts can become painful, especially with chronic pancreatitis, and can cause early satiety and weight loss when their size affects the stomach and bowel. Symptomatic pseudocysts can successfully be drained with via surgical, radiologic, or endoscopic drainage.
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Affiliation(s)
- Jack Braha
- Division of Gastroenterology, Mount Sinai Medical Center-Brooklyn, The Greater New York Endoscopy Surgical Center, 2211 Emmons Avenue, Brooklyn, NY 11235, USA
| | - Scott Tenner
- State University of New York, The Greater New York Endoscopy Center, 2211 Emmons Avenue, Brooklyn, NY 11235, USA.
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19
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Abstract
Acute pancreatitis represents a disorder characterized by acute necroinflammatory changes of the pancreas and is histologically characterized by acinar cell destruction. Diagnosed clinically with the Revised Atlanta Criteria, and with alcohol and cholelithiasis/choledocholithiasis as the two most prominent antecedents, acute pancreatitis ranks first amongst gastrointestinal diagnoses requiring admission and 21st amongst all diagnoses requiring hospitalization with estimated costs approximating 2.6 billion dollars annually. Complications arising from acute pancreatitis follow a progression from pancreatic/peripancreatic fluid collections to pseudocysts and from pancreatic/peripancreatic necrosis to walled-off necrosis that typically occur over the course of a 4-week interval. Treatment relies heavily on fluid resuscitation and nutrition with advanced endoscopic techniques and cholecystectomy utilized in the setting of gallstone pancreatitis. When necessity dictates a drainage procedure (persistent abdominal pain, gastric or duodenal outlet obstruction, biliary obstruction, and infection), an endoscopic ultrasound with advanced endoscopic techniques and technology rather than surgical intervention is increasingly being utilized to manage symptomatic pseudocysts and walled-off pancreatic necrosis by performing a cystogastrostomy.
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20
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Plasma Level of Soluble Urokinase-type Plasminogen Activator Receptor Predicts the Severity of Acute Alcohol Pancreatitis. Pancreas 2017; 46:77-82. [PMID: 27841794 DOI: 10.1097/mpa.0000000000000730] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Systemic levels of soluble urokinase-type plasminogen activator receptor (suPAR) are increased in various inflammatory and infectious diseases. We investigated the activation and prognostic value of plasma suPAR (P-suPAR) in patients experiencing their first acute alcohol pancreatitis (AAP). METHODS From prospectively collected data, we measured P-suPAR concentrations in 104 patients with AAP during hospitalization and again after discharge. RESULTS According to the revised Atlanta classification, pancreatitis was moderately severe in 29 (28%) and severe in 6 (6%) patients and these severities were combined for further analysis (non-mild AAP, n = 35; 34%). Median P-suPAR levels were significantly higher in patients with AAP during hospitalization than after discharge (4.8 vs 3.1 ng/mL; P < 0.001) and in non-mild compared to mild AAP (6.2 vs 4.2 ng/mL; P < 0.001). When the analysis was made 1 to 4 days after admission (n = 68), the area under the curve was 0.81 (95% confidence interval, 0.70-0.92). P-suPAR was found to be a better prognostic marker in AAP than C-reactive protein, hematocrit, or creatinine. CONCLUSIONS P-suPAR concentrations are elevated in AAP and correlate with the severity of the disease. These results suggest that P-suPAR may have potential to serve as a novel prognostic marker for AAP severity on admission.
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21
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Singh VK, Gardner TB, Papachristou GI, Rey-Riveiro M, Faghih M, Koutroumpakis E, Afghani E, Acevedo-Piedra NG, Seth N, Sinha A, Quesada-Vázquez N, Moya-Hoyo N, Sánchez-Marin C, Martínez J, Lluís F, Whitcomb DC, Zapater P, de-Madaria E. An international multicenter study of early intravenous fluid administration and outcome in acute pancreatitis. United European Gastroenterol J 2016; 5:491-498. [PMID: 28588879 DOI: 10.1177/2050640616671077] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/29/2016] [Indexed: 12/16/2022] Open
Abstract
AIMS Early aggressive fluid resuscitation in acute pancreatitis is frequently recommended but its benefits remain unproven. The aim of this study was to determine the outcomes associated with early fluid volume administration in the emergency room (FVER) in patients with acute pancreatitis. METHODS A four-center retrospective cohort study of 1010 patients with acute pancreatitis was conducted. FVER was defined as any fluid administered from the time of arrival to the emergency room to 4 h after diagnosis of acute pancreatitis, and was divided into tertiles: nonaggressive (<500 ml), moderate (500 to 1000 ml), and aggressive (>1000 ml). RESULTS Two hundred sixty-nine (26.6%), 427 (42.3%), and 314 (31.1%) patients received nonaggressive, moderate, and aggressive FVER respectively. Compared with the nonaggressive fluid group, the moderate group was associated with lower rates of local complications in univariable analysis, and interventions, both in univariable and multivariable analysis (adjusted odds ratio (95% confidence interval): 0.37 (0.14-0.98)). The aggressive resuscitation group was associated with a significantly lower need for interventions, both in univariable and multivariable analysis (adjusted odds ratio 0.21 (0.05-0.84)). Increasing fluid administration categories were associated with decreasing hospital stay in univariable analysis. CONCLUSIONS Early moderate to aggressive FVER was associated with lower need for invasive interventions.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Timothy B Gardner
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, USA
| | - Georgios I Papachristou
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Mónica Rey-Riveiro
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Mahya Faghih
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Efstratios Koutroumpakis
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Elham Afghani
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Nelly G Acevedo-Piedra
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Nikhil Seth
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Amitasha Sinha
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, USA
| | - Noé Quesada-Vázquez
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Neftalí Moya-Hoyo
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Claudia Sánchez-Marin
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Juan Martínez
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Félix Lluís
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - David C Whitcomb
- Division of Gastroenterology and Hepatology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Pedro Zapater
- Clinical Pharmacology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
| | - Enrique de-Madaria
- Department of Gastroenterology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL - Fundación FISABIO), Spain
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Antonini F, Pezzilli R, Angelelli L, Macarri G. Pancreatic disorders in inflammatory bowel disease. World J Gastrointest Pathophysiol 2016; 7:276-282. [PMID: 27574565 PMCID: PMC4981767 DOI: 10.4291/wjgp.v7.i3.276] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/08/2016] [Accepted: 07/20/2016] [Indexed: 02/06/2023] Open
Abstract
An increased incidence of pancreatic disorders either acute pancreatitis or chronic pancreatitis has been recorded in patients with inflammatory bowel disease (IBD) compared to the general population. Although most of the pancreatitis in patients with IBD seem to be related to biliary lithiasis or drug induced, in some cases pancreatitis were defined as idiopathic, suggesting a direct pancreatic damage in IBD. Pancreatitis and IBD may have similar presentation therefore a pancreatic disease could not be recognized in patients with Crohn's disease and ulcerative colitis. This review will discuss the most common pancreatic diseases seen in patients with IBD.
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23
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Bierma MJ, Coffey MJ, Nightingale S, van Rheenen PF, Ooi CY. Predicting severe acute pancreatitis in children based on serum lipase and calcium: A multicentre retrospective cohort study. Pancreatology 2016; 16:529-34. [PMID: 27161174 DOI: 10.1016/j.pan.2016.04.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 03/26/2016] [Accepted: 04/10/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE This study aims to identify predictors of severe paediatric AP based on laboratory trends and peak/trough values on day 2 (D2) after presentation. The performance of identified predictors was first assessed and then combined with the previously validated sensitive predictor serum lipase ≥7 times the upper limit of normal (× ULN) on day 1 (D1). METHODS A retrospective review of children with AP (January 2000-July 2011) was performed at three tertiary referral hospitals (two in Australia, one in the Netherlands). Trends of candidate predictors were analysed using the percentage change from D1 to D2 or peak/trough values within 48 h after presentation. RESULTS 175 AP episodes (including 50 severe episodes [29%]) were identified. Serum lipase ≥50% decrease on D2 (sensitivity 73%, specificity 54%) and calcium trough ≤2.15 mmol/L within 48 h (sensitivity 59%, specificity 81%) were identified as statistically significant predictors for severe AP. By combining the newly identified predictors with the previously validated predictor serum lipase ≥7× ULN on D1 (sensitivity 82%, specificity 53%), specificity improved to predict severe AP on D2 with the addition of: (i) serum lipase ≥50% decrease (sensitivity 67%, specificity 79%), or (ii) trough calcium ≤2.15 mmol/L (sensitivity 46%, specificity 89%). CONCLUSIONS Serum lipase and calcium, may be helpful in predicting severity of paediatric AP. There may be a clinical role on D1 for using serum lipase ≥7× ULN (high sensitivity), and on D2 for combining D1 serum lipase ≥7× ULN with calcium trough ≤2.15 mmol/L within 48 h (high specificity) to help predict severe paediatric AP.
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Affiliation(s)
- Marrit J Bierma
- Department of Paediatric Gastroenterology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael J Coffey
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Scott Nightingale
- Department of Gastroenterology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia; Discipline of Paediatrics and Child Health, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Patrick F van Rheenen
- Department of Paediatric Gastroenterology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Chee Y Ooi
- Discipline of Paediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Department of Gastroenterology, Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia.
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24
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David SS. Acute Pancreatitis. CLINICAL PATHWAYS IN EMERGENCY MEDICINE 2016. [PMCID: PMC7120857 DOI: 10.1007/978-81-322-2710-6_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Landahl P, Ansari D, Andersson R. Severe Acute Pancreatitis: Gut Barrier Failure, Systemic Inflammatory Response, Acute Lung Injury, and the Role of the Mesenteric Lymph. Surg Infect (Larchmt) 2015; 16:651-656. [PMID: 26237406 DOI: 10.1089/sur.2015.034] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Severe acute pancreatitis (AP) often leads to distant organ dysfunction with a high morbidity and mortality rate. The most common and earliest organ to fail is the lungs, but the exact pathophysiological mechanisms underlying the disease are still unclear. No successful targeted therapy exists, and treatment is limited to organ supportive care. It is believed that the gut is involved in the development of distant organ failure, as severe AP is associated with changes in the microcirculation, gut permeability/motility, bacterial translocation, and activation of the gut-associated lymphoid tissue (GALT). Experimental evidence implicates the mesenteric lymph as a primary route for these toxic factors to gain access to the systemic circulation. This literature overview was made to survey these mechanisms and the potential of surgical interventions on the thoracic duct as a means of therapy. METHODS Review of the pertinent English-language literature. RESULTS In experimental studies, interruption of mesenteric lymphatic flow has preventive qualities for acute lung injury (ALI) in the setting of critical illness with various etiologies. Experimentally, diversion of mesenteric lymph is able to prevent ALI if done before its development, whereas a later intervention partially reduces the lung damage. Few studies have investigated surgical approaches to the thoracic duct in human beings under these circumstances, and the ones that have been performed are of low quality and have conflicting results. It seems likely that the intervention would need to be performed prior to the development of ALI to obtain maximum benefits, which complicates its application clinically, because prediction of ALI cannot today be done with high precision. CONCLUSION Studies are ongoing to identify the factors carried in mesenteric lymph that may cause end-organ failure (e.g., ALI) and, once recognized, might allow the development of novel targeted agents that would modify the disease course.
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Affiliation(s)
- Per Landahl
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital , Lund, Sweden
| | - Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital , Lund, Sweden
| | - Roland Andersson
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital , Lund, Sweden
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Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, Itoi T, Sata N, Gabata T, Igarashi H, Kataoka K, Hirota M, Kadoya M, Kitamura N, Kimura Y, Kiriyama S, Shirai K, Hattori T, Takeda K, Takeyama Y, Hirota M, Sekimoto M, Shikata S, Arata S, Hirata K. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:405-432. [PMID: 25973947 DOI: 10.1002/jhbp.259] [Citation(s) in RCA: 281] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. METHODS A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. RESULTS Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. CONCLUSIONS The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.
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Affiliation(s)
- Masamichi Yokoe
- General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, KitaKyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic & Transplant Surgery Mie University Graduate School of Medicine, Mie, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University, School of Medical Science, Kanazawa, Japan
| | - Hisato Igarashi
- Clinical Education Center, Kyushu University Hospital, Fukuoka, Japan
| | - Keisho Kataoka
- Otsu Municipal Hospital, Shiga
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiko Hirota
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Masumi Kadoya
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Takayuki Hattori
- Department of Radiology, Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
| | - Kazunori Takeda
- Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miho Sekimoto
- The University of Tokyo Graduate School of Public Policy, Health Policy Unit, Tokyo
| | - Satoru Shikata
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Shinju Arata
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Koichi Hirata
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
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Early prediction of persistent organ failure by soluble CD73 in patients with acute pancreatitis*. Crit Care Med 2015; 42:2556-64. [PMID: 25126879 DOI: 10.1097/ccm.0000000000000550] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE New biomarkers are needed to better predict the severity of acute pancreatitis. CD73/ecto-5'-nucleotidase is an enzyme that generates adenosine, which dampens inflammation and improves vascular barrier function in several disease models. CD73 also circulates in a soluble form in the blood. We studied whether levels of soluble form of CD73 predict the development of organ failure in acute pancreatitis. DESIGN A prospective cohort study of patients with acute pancreatitis from 2003 to 2007. SETTING Admissions to the biggest tertiary care hospital in Finland. PATIENTS One hundred sixty-one patients with acute pancreatitis, of which 107 were subclassified according to the revised Atlanta criteria into mild, 29 into moderately severe and 25 into severe. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Serum and blood cell samples were collected at admission. Protein levels of soluble form of CD73 in serum were determined using a novel enzyme-linked immunosorbent assay, activity of soluble form of CD73 using radioactive enzyme assays, and CD73 messenger RNA levels from leukocytes using quantitative polymerase chain reaction. Activity and protein concentration of soluble form of CD73, and messenger RNA level of CD73 all decreased along with the disease severity (p ≤ 0.01 for all). The activity of soluble form of CD73 at admission predicted the development of the severe pancreatitis in different groups of the patients. The area under the receiver-operating characteristic curve value for activity of soluble form of CD73 was 0.65 (95% CI, 0.51-0.80) among a subgroup of patients comprising moderately severe and severe disease, 0.79 (95% CI, 0.69-0.88) among all patients including mild pancreatitis, and 0.75 (95% CI, 0.60-0.89) among patients who had no signs of organ failure (modified Marshall score < 2) at admission. Especially, in the last-mentioned group, activity of soluble form of CD73 was better than C-reactive protein or creatinine in predicting the severe pancreat CONCLUSIONS : Activity of soluble form of CD73 at admission to hospital has prognostic value in predicting the development of the severe form of acute pancreatitis.
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Aggarwal A, Manrai M, Kochhar R. Fluid resuscitation in acute pancreatitis. World J Gastroenterol 2014; 20:18092-18103. [PMID: 25561779 PMCID: PMC4277949 DOI: 10.3748/wjg.v20.i48.18092] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/03/2014] [Accepted: 10/14/2014] [Indexed: 02/06/2023] Open
Abstract
Acute pancreatitis remains a clinical challenge, despite an exponential increase in our knowledge of its complex pathophysiological changes. Early fluid therapy is the cornerstone of treatment and is universally recommended; however, there is a lack of consensus regarding the type, rate, amount and end points of fluid replacement. Further confusion is added with the newer studies reporting better results with controlled fluid therapy. This review focuses on the pathophysiology of fluid depletion in acute pancreatitis, as well as the rationale for fluid replacement, the type, optimal amount, rate of infusion and monitoring of such patients. The basic goal of fluid epletion should be to prevent or minimize the systemic response to inflammatory markers. For this review, various studies and reviews were critically evaluated, along with authors' recommendations, for predicted severe or severe pancreatitis based on the available evidence.
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Weitz G, Woitalla J, Wellhöner P, Schmidt K, Büning J, Fellermann K. Detrimental effect of high volume fluid administration in acute pancreatitis - a retrospective analysis of 391 patients. Pancreatology 2014; 14:478-83. [PMID: 25451185 DOI: 10.1016/j.pan.2014.07.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/23/2014] [Accepted: 07/09/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early fluid resuscitation is recommended for the therapy of acute pancreatitis in order to prevent complications. There are, however, no convincing data supporting this approach. METHODS We reviewed 391 consecutive cases of confirmed acute pancreatitis. Admitting physicians had been advised to administer an aggressive fluid resuscitation in the early phase of disease, if possible. We tested whether disease severity according to the revised Atlanta Classification, local complications, and maximum C-reactive protein levels were predictable by the initial volume therapy in logistic and linear regression models, respectively. We also determined which parameters on admission encouraged a more aggressive fluid resuscitation. RESULTS The recorded fluid administered within the first 24 h was 5300 [3760; 7100] ml (median [1st; 3rd quartile]). More aggressive volume therapy was associated with disease severity and a higher rate of local complications. There was a linear relationship between administered volume and the maximum C-reactive protein. The amount of administered fluid was significantly attributed to age, hematocrit, and white blood cell count on admission. When adjusted for these parameters the impact of administered volume on outcome was still present but attenuated. CONCLUSIONS We found detrimental effects of fluid therapy on major outcome parameters throughout the whole range of administered volume. More volume was administered in younger patients and in patients with evidence of hemoconcentration and inflammation. The adverse effects of volume therapy persisted after elimination of these parameters. Caution should therefore be advised with regards to volume therapy in patients with acute pancreatitis.
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Affiliation(s)
- Gunther Weitz
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Julia Woitalla
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Peter Wellhöner
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Klaus Schmidt
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Jürgen Büning
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Klaus Fellermann
- Medical Department I, Gastroenterology, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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Talukdar R, Ingale P, Choudhury HP, Dhingra R, Shetty S, Joshi H, Pradeep KR, Mahapatra L, Mazumder S, Pradeep JK, Thakker B, Chaudhary A, Kumar A, Nageshwar Reddy D, Rao GV, Ramesh H, Bhat N, Garg P, Kochhar R. Antibiotic use in acute pancreatitis: an Indian multicenter observational study. Indian J Gastroenterol 2014; 33:458-65. [PMID: 25138788 DOI: 10.1007/s12664-014-0494-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/02/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Prophylactic antibiotics are used frequently for acute pancreatitis (AP). Consensus guidelines do not recommend this currently, based on moderate quality evidence. In this study, we aimed to evaluate the antibiotic use pattern in AP in India and propose a risk-directed approach to antibiotic use in AP. MATERIAL AND METHODS This multicenter study was conducted from 1 May 2013 to 31 July 2013. Eleven participants from eight tertiary centers completed a questionnaire that captured patient demographics, etiology, admission status, presence of (peri)pancreatic necrosis, severity of pancreatitis, details of antibiotic use, and clinical outcomes (total hospital stay, persistent organ failure, need for ICU, total days in ICU, development of infections, in-hospital mortality). RESULTS A total of 200 proformas were analyzed. Seventy-three (36.5 %) had acute necrotizing pancreatitis (ANP). Eighty-nine (44.5 %), 52 (26 %), and 55 (27.5 %) patients had mild AP (MAP), moderately severe AP (MSAP), and severe AP (SAP), respectively. Forty-five (22.5 %) patients developed infections (unifocal 29; multifocal 16). One hundred thirty-four (67 %) patients received antibiotics, of which 89 (66.4 %) received prophylactic, while 45 (33.6 %) received therapeutic antibiotics. The distribution of antibiotic use according to the severity of AP was 43 (48.3 %) in patients with MAP (prophylactic in 41; therapeutic in 2), 36 (69.2 %) in patients with MSAP (prophylactic in 29; therapeutic in 7), and 55 (100 %) in patients with SAP (prophylactic in 19; therapeutic in 36). Therapeutic antibiotics were prescribed based on culture and sensitivity in 21 (46.7 %) patients. CONCLUSIONS Despite nonrecommendation, prophylactic antibiotics are used frequently in AP. We emphasize on the need for multicenter randomized controlled trials on prophylactic antibiotics for AP based on a risk-directed approach, rather than a "blanket approach."
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Affiliation(s)
- Rupjyoti Talukdar
- Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad, 500 082, India
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Early factors associated with fluid sequestration and outcomes of patients with acute pancreatitis. Clin Gastroenterol Hepatol 2014; 12:997-1002. [PMID: 24183957 DOI: 10.1016/j.cgh.2013.10.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 09/25/2013] [Accepted: 10/16/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Predicting level of fluid sequestration could help identify patients with acute pancreatitis (AP) who need more or less aggressive fluid resuscitation. We investigated factors associated with level of fluid sequestration in the first 48 hours after hospital admission in patients with AP and effects on outcome. METHODS We analyzed data from consecutive adult patients with AP admitted to the Brigham and Women's Hospital in Boston, Massachusetts, from June 2005 to December 2007 (n = 266) or the Alicante University General Hospital in Spain from September 2010 to December 2012 (n = 137). Level of fluid sequestration in the first 48 hours after hospital admission was calculated by subtracting the total amount of fluid administered and lost in the first 48 hours of hospitalization. Demographic and clinical variables obtained in the emergency department were analyzed to identify factors associated with level of fluid sequestration in the first 48 hours after hospital admission. Outcome assessed included length of hospital stay, acute fluid collection(s), pancreatic necrosis, persistent organ failure, and mortality. RESULTS The median level of fluid sequestration in the first 48 hours after hospital admission was 3.2 L (1.4-5 L). The simple and multiple linear regression models showed that younger age, alcohol etiology, hematocrit, glucose, and systemic inflammatory response syndrome were significantly associated with increased levels of fluid sequestration in the first 48 hours after hospital admission. Increased level of fluid sequestration in the first 48 hours was significantly associated with longer hospital stays and higher rates of acute fluid collection, pancreatic necrosis, and persistent organ failure. There was a nonsignificant trend toward a higher level of fluid sequestration in the first 48 hours among patients who died. CONCLUSION Age, alcoholic etiology of AP, hematocrit, glucose, and presence of systemic inflammatory response syndrome in the emergency department were independent predictors of increased levels of fluid sequestration in the first 48 hours after hospital admission. These patients have higher risks of local and systemic complications and longer hospital stays.
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A combined paging alert and web-based instrument alters clinician behavior and shortens hospital length of stay in acute pancreatitis. Am J Gastroenterol 2014; 109:306-15. [PMID: 24594946 PMCID: PMC5565843 DOI: 10.1038/ajg.2013.282] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There are many published clinical guidelines for acute pancreatitis (AP). Implementation of these recommendations is variable. We hypothesized that a clinical decision support (CDS) tool would change clinician behavior and shorten hospital length of stay (LOS). DESIGN/SETTING Observational study, entitled, The AP Early Response (TAPER) Project. Tertiary center emergency department (ED) and hospital. PARTICIPANTS Two consecutive samplings of patients having ICD-9 code (577.0) for AP were generated from the emergency department (ED) or hospital admissions. Diagnosis of AP was based on conventional Atlanta criteria. The Pre-TAPER-CDS-Tool group (5/30/06-6/22/07) had 110 patients presenting to the ED with AP per 976 ICD-9 (577.0) codes and the Post-TAPER-CDS-Tool group (5/30/06-6/22/07) had 113 per 907 ICD-9 codes (7/14/10-5/5/11). INTERVENTION The TAPER-CDS-Tool, developed 12/2008-7/14/2010, is a combined early, automated paging-alert system, which text pages ED clinicians about a patient with AP and an intuitive web-based point-of-care instrument, consisting of seven early management recommendations. RESULTS The pre- vs. post-TAPER-CDS-Tool groups had similar baseline characteristics. The post-TAPER-CDS-Tool group met two management goals more frequently than the pre-TAPER-CDS-Tool group: risk stratification (P<0.0001) and intravenous fluids >6L/1st 0-24 h (P=0.0003). Mean (s.d.) hospital LOS was significantly shorter in the post-TAPER-CDS-Tool group (4.6 (3.1) vs. 6.7 (7.0) days, P=0.0126). Multivariate analysis identified four independent variables for hospital LOS: the TAPER-CDS-Tool associated with shorter LOS (P=0.0049) and three variables associated with longer LOS: Japanese severity score (P=0.0361), persistent organ failure (P=0.0088), and local pancreatic complications (<0.0001). CONCLUSIONS The TAPER-CDS-Tool is associated with changed clinician behavior and shortened hospital LOS, which has significant financial implications.
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Stošić B, Janković R, Stanković D, Veselinović I. VOLUME THERAPY IN ACUTE PANCREATITIS. ACTA MEDICA MEDIANAE 2013. [DOI: 10.5633/amm.2013.0308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108:1400-15; 1416. [PMID: 23896955 DOI: 10.1038/ajg.2013.218] [Citation(s) in RCA: 1373] [Impact Index Per Article: 114.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 06/18/2013] [Indexed: 02/06/2023]
Abstract
This guideline presents recommendations for the management of patients with acute pancreatitis (AP). During the past decade, there have been new understandings and developments in the diagnosis, etiology, and early and late management of the disease. As the diagnosis of AP is most often established by clinical symptoms and laboratory testing, contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI) of the pancreas should be reserved for patients in whom the diagnosis is unclear or who fail to improve clinically. Hemodynamic status should be assessed immediately upon presentation and resuscitative measures begun as needed. Patients with organ failure and/or the systemic inflammatory response syndrome (SIRS) should be admitted to an intensive care unit or intermediary care setting whenever possible. Aggressive hydration should be provided to all patients, unless cardiovascular and/or renal comorbidites preclude it. Early aggressive intravenous hydration is most beneficial within the first 12-24 h, and may have little benefit beyond. Patients with AP and concurrent acute cholangitis should undergo endoscopic retrograde cholangiopancreatography (ERCP) within 24 h of admission. Pancreatic duct stents and/or postprocedure rectal nonsteroidal anti-inflammatory drug (NSAID) suppositories should be utilized to lower the risk of severe post-ERCP pancreatitis in high-risk patients. Routine use of prophylactic antibiotics in patients with severe AP and/or sterile necrosis is not recommended. In patients with infected necrosis, antibiotics known to penetrate pancreatic necrosis may be useful in delaying intervention, thus decreasing morbidity and mortality. In mild AP, oral feedings can be started immediately if there is no nausea and vomiting. In severe AP, enteral nutrition is recommended to prevent infectious complications, whereas parenteral nutrition should be avoided. Asymptomatic pancreatic and/or extrapancreatic necrosis and/or pseudocysts do not warrant intervention regardless of size, location, and/or extension. In stable patients with infected necrosis, surgical, radiologic, and/or endoscopic drainage should be delayed, preferably for 4 weeks, to allow the development of a wall around the necrosis.
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de-Madaria E. [Fluid therapy in acute pancreatitis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2013; 36:631-40. [PMID: 23988650 DOI: 10.1016/j.gastrohep.2013.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Accepted: 01/15/2013] [Indexed: 10/26/2022]
Abstract
Severe acute pancreatitis (AP) is associated with an increased need for fluids due to fluid sequestration and, in the most severe cases, with decreased peripheral vascular tone. For several decades, clinical practice guidelines have recommended aggressive fluid therapy to improve the prognosis of AP. This recommendation is based on theoretical models, animal studies, and retrospective studies in humans. Recent studies suggest that aggressive fluid administration in all patients with AP could have a neutral or harmful effect. Fluid therapy based on Ringer's lactate could improve the course of the disease, although further studies are needed to confirm this possibility. Most patients with AP do not require invasive monitoring of hemodynamic parameters to guide fluid therapy administration. Moreover, the ability of these parameters to improve prognosis has not been demonstrated.
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Affiliation(s)
- Enrique de-Madaria
- Unidad de Patología Pancreática, Hospital General Universitario de Alicante, Alicante, España.
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Contrasts and comparisons between childhood and adult onset acute pancreatitis. Pancreatology 2013; 13:429-35. [PMID: 23890143 DOI: 10.1016/j.pan.2013.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 06/18/2013] [Accepted: 06/19/2013] [Indexed: 12/11/2022]
Abstract
Acute pancreatitis (AP) in children is an increasingly recognised clinical entity notably different from the adults with respect to incidence, aetiology, severity and outcome. Yet our current understanding and approach to the management of paediatric pancreatitis is based almost entirely on adult studies. Acute recurrent pancreatitis (ARP) in children is more likely associated with various genetic factors, some of which have been relatively well characterised and others are in an evolving phase. The aim of this review is to summarise current knowledge, highlight any recent advances and contrast the paediatric and adult forms of this condition.
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Zhao G, Zhang JG, Wu HS, Tao J, Qin Q, Deng SC, Liu Y, Liu L, Wang B, Tian K, Li X, Zhu S, Wang CY. Effects of different resuscitation fluid on severe acute pancreatitis. World J Gastroenterol 2013; 19:2044-2052. [PMID: 23599623 PMCID: PMC3623981 DOI: 10.3748/wjg.v19.i13.2044] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 10/12/2012] [Accepted: 12/17/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare effects of different resuscitation fluid on microcirculation, inflammation, intestinal barrier and clinical results in severe acute pancreatitis (SAP).
METHODS: One hundred and twenty patients with SAP were enrolled at the Pancreatic Disease Institute between January 2007 and March 2010. The patients were randomly treated with normal saline (NS group), combination of normal saline and hydroxyethyl starch (HES) (SH group), combination of normal saline, hydroxyethyl starch and glutamine (SHG group) in resuscitation. The ratio of normal saline to HES in the SH and SHG groups was 3:1. The glutamine (20% glutamine dipeptide, 100 mL/d) was supplemented into the resuscitation liquid in the SHG group. Complications and outcomes including respiratory and abdominal infection, sepsis, abdominal hemorrhage, intra-abdominal hypertension, abdominal compartment syndrome (ACS), renal failure, acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), operation intervention, length of intensive care unit stay, length of hospital stay, and mortality at 60 d were compared. Moreover, blood oxygen saturation (SpO2), gastric intramucosal pH value (pHi), intra-abdominal pressure (IAP), inflammation cytokines, urine lactulose/mannitol (L/M) ratio, and serum endotoxin were investigated to evaluate the inflammatory reaction and gut barrier.
RESULTS: Compared to the NS group, patients in the SH and SHG groups accessed the endpoint more quickly (3.9 ± 0.23 d and 4.1 ± 0.21 d vs 5.8 ± 0.25 d, P < 0.05) with less fluid volume (67.26 ± 28.53 mL/kg/d, 61.79 ± 27.61 mL/kg per day vs 85.23 ± 21.27 mL/kg per day, P < 0.05). Compared to the NS group, incidence of renal dysfunction, ARDS, MODS and ACS in the SH and SHG groups was obviously lower. Furthermore, incidence of respiratory and abdominal infection was significantly decreased in the SH and SHG groups, while no significant difference in sepsis was seen. Moreover, less operation time was needed in the SH and SHG group than the NS group, but the difference was not significant. The mortality did not differ significantly among these groups. Blood SpO2 and gastric mucosal pHi in the SH and SHG groups increased more quickly than in the NS group, while IAP was significantly decreased in the SH and SHG group. Moreover, the serum tumor necrosis factor-α, interleukin-8 and C-reactive protein levels in the SH and SHG groups were obviously lower than in the NS group at each time point. Furthermore, urine L/M ratio and serum endotoxin were significantly lower in the SH group and further decreased in the SHG group.
CONCLUSION: Results indicated that combination of normal saline, HES and glutamine are more efficient in resuscitation of SAP by relieving inflammation and sustaining the intestinal barrier.
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Trikudanathan G, Navaneethan U, Vege SS. Current controversies in fluid resuscitation in acute pancreatitis: a systematic review. Pancreas 2012; 41:827-34. [PMID: 22781906 DOI: 10.1097/mpa.0b013e31824c1598] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute pancreatitis (AP) is a common inflammatory disorder of the pancreas resulting in considerable morbidity and mortality. Aggressive intravenous fluid resuscitation generally is recommended in all patients with AP and remains the cornerstone of management of these patients. However, the optimal rate, type, and the goal of resuscitation remain unclear. The purpose of this review was to give an insight about the pathophysiologic alterations in the pancreatic microcirculation that occur in AP, the markers for early recognition of severity of pancreatitis, the optimal fluid, and timing and extent of fluid resuscitation. An early elevated hematocrit, blood urea nitrogen, or creatinine should prompt clinicians to institute more intensive early resuscitation measures. Crystalloids are the currently recommended fluids for management of these patients. Current studies are underway to determine the optimal end points of fluid resuscitation that determine outcome.
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Affiliation(s)
- Guru Trikudanathan
- Department of Internal Medicine, University of Connecticut Medical Center, Farmington, CT, USA
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39
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Case matched comparison study of the necrosectomy by retroperitoneal approach with transperitoneal approach for necrotizing pancreatitis in patients with CT severity score of 7 and above. Int J Surg 2012; 10:587-92. [DOI: 10.1016/j.ijsu.2012.09.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Revised: 09/01/2012] [Accepted: 09/11/2012] [Indexed: 02/07/2023]
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de-Madaria E, Soler-Sala G, Sánchez-Payá J, Lopez-Font I, Martínez J, Gómez-Escolar L, Sempere L, Sánchez-Fortún C, Pérez-Mateo M. Influence of fluid therapy on the prognosis of acute pancreatitis: a prospective cohort study. Am J Gastroenterol 2011; 106:1843-50. [PMID: 21876561 DOI: 10.1038/ajg.2011.236] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Although aggressive fluid therapy during the first days of hospitalization is recommended by most guidelines and reviews on acute pancreatitis (AP), this recommendation is not supported by any direct evidence. We aimed to evaluate the association between the amount of fluid administered during the initial 24 h of hospitalization and the incidence of organ failure (OF), local complications, and mortality. METHODS This was a prospective cohort study. We included consecutive adult patients admitted with AP. Local complications and OF were defined according to the Atlanta Classification. Persistent OF was defined as OF of >48-h duration. Patients were divided into three groups according to the amount of fluid administered during the initial 24 h: group A: <3.1 l (less than the first quartile), group B: 3.1-4.1 l (between the first and third quartiles), and group C: >4.1 l (more than the third quartile). RESULTS A total of 247 patients were analyzed. Administration of >4.1 l during the initial 24 h was significantly and independently associated with persistent OF, acute collections, respiratory insufficiency, and renal insufficiency. Administration of <3.1 l during the initial 24 h was not associated with OF, local complications, or mortality. Patients who received between 3.1 and 4.1 l during the initial 24 h had an excellent outcome. CONCLUSIONS In our study, administration of a small amount of fluid during the initial 24 h was not associated with a poor outcome. The need for a great amount of fluid during the initial 24 h was associated with a poor outcome; therefore, this group of patients must be carefully monitored.
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41
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Warndorf MG, Kurtzman JT, Bartel MJ, Cox M, Mackenzie T, Robinson S, Burchard PR, Gordon SR, Gardner TB. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011; 9:705-9. [PMID: 21554987 PMCID: PMC3143229 DOI: 10.1016/j.cgh.2011.03.032] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/01/2011] [Accepted: 03/27/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Early fluid resuscitation is recommended to reduce morbidity and mortality among patients with acute pancreatitis, although the impact of this intervention has not been quantified. We investigated the association between early fluid resuscitation and outcome of patients admitted to the hospital with acute pancreatitis. METHODS Nontransfer patients admitted to our center with acute pancreatitis from 1985-2009 were identified retrospectively. Patients were stratified into groups on the basis of early (n = 340) or late resuscitation (n = 94). Early resuscitation was defined as receiving ≥one-third of the total 72-hour fluid volume within 24 hours of presentation, whereas late resuscitation was defined as receiving ≤one-third of the total 72-hour fluid volume within 24 hours of presentation. The primary outcomes were frequency of systemic inflammatory response syndrome (SIRS), organ failure, and death. RESULTS Early resuscitation was associated with decreased SIRS, compared with late resuscitation, at 24 hours (15% vs 32%, P = .001), 48 hours (14% vs 33%, P = .001), and 72 hours (10% vs 23%, P = .01), as well as reduced organ failure at 72 hours (5% vs 10%, P < .05), a lower rate of admission to the intensive care unit (6% vs 17%, P < .001), and a reduced length of hospital stay (8 vs 11 days, P = .01). Subgroup analysis demonstrated that these benefits were more pronounced in patients with interstitial rather than severe pancreatitis at admission. CONCLUSIONS In patients with acute pancreatitis, early fluid resuscitation was associated with reduced incidence of SIRS and organ failure at 72 hours. These effects were most pronounced in patients admitted with interstitial rather than severe disease.
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42
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The role of antibiotics in the management of patients with acute necrotizing pancreatitis. Curr Infect Dis Rep 2011; 12:13-8. [PMID: 21308495 DOI: 10.1007/s11908-009-0071-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Our understanding of the role of antibiotics in the management of patients with pancreatic necrosis has changed over the past 5 years. Initial studies suggested that antibiotics were useful in preventing infection of necrosis, septic complications, and mortality in patients with acute pancreatitis; however, more recent, better-designed studies established that prophylactic antibiotics are not helpful. In the absence of infection, sterile necrosis is treated conservatively. With insufficient evidence to recommend antibiotics, these agents should be reserved to treat established infection of pancreatic necrosis. Infected necrosis is treated by targeting microbes with pancreatic-penetrating antibiotics (eg, carbapenems, quinolones in combination with metronidazole, or high-dose cephalosporins). If the patient with infected necrosis remains septic or deteriorates, surgical intervention should be performed urgently. Stable patients with infected necrosis can be managed more conservatively in a closely monitored environment. Recent studies suggest that many patients can clear the infection with antibiotics, but even if they do not clear the infection, delay in surgery decreases the mortality rate. Delaying surgery by using antibiotics may allow use of less invasive procedures if drainage is needed. The timing and method of interventions must be individualized based on the patient's condition, anatomic complications, patient's preference after informed consent, and expertise available at the institution.
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43
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Zerem E, Imamović G, Sušić A, Haračić B. Step-up approach to infected necrotising pancreatitis: a 20-year experience of percutaneous drainage in a single centre. Dig Liver Dis 2011; 43:478-483. [PMID: 21478061 DOI: 10.1016/j.dld.2011.02.020] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 02/12/2011] [Accepted: 02/26/2011] [Indexed: 12/11/2022]
Abstract
AIM To evaluate the efficacy of step-up approach to infected necrotising pancreatitis. METHODS Retrospective analysis of 86 patients treated by step-up approach from 1989 to 2009. Infection was confirmed by examination of aspirated material or by presence of free pancreatic gas at contrast-enhanced computed tomography. Conservative treatment was initially attempted in all patients; percutaneous catheter drainage was performed when conservative therapy failed; surgery was planned only if no clinical improvement was observed. Primary outcome was mortality. RESULTS Fifteen patients (17.4%) were successfully treated with conservative treatment only. Percutaneous catheter drainage was performed in 69 (80.2%). Eight patients (9.3%) died, two at week 1 without drainage or surgery and six after percutaneous catheter drainage and surgery. Eleven patients were converted to surgery (12.8%). Organ failure occurred in 59/86 (68.6%) and multiorgan failure in 25/86 (29.1%). Median (interquartile ranges) hospital stay and catheter dwell times were 13 (9-47) and 15 (7-34) days, respectively. There were 2.61 catheter problems and 1.68 catheter changes per patient. CONCLUSIONS The step-up approach is an effective and safe strategy for the treatment of infected necrotising pancreatitis. Percutaneous drainage can avert the need for surgery in the majority of patients.
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Affiliation(s)
- Enver Zerem
- University Clinical Center, Tuzla, Bosnia and Herzegovina.
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44
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Abstract
OBJECTIVE Early aggressive intravenous hydration is believed to prevent morbidity and mortality by preventing intravascular volume depletion and maintaining perfusion of the pancreas possibly preventing pancreatic necrosis. The following study was initiated to determine the relationship between the observed decrease in mortality and the role of early aggressive hydration. METHODS A consecutive series of patients with acute pancreatitis from a single community hospital in 1998 were compared to a consecutive series of patients with acute pancreatitis from the same institution in 2008. RESULTS Significantly more patients developed pancreatic necrosis; 26 (15%) of 173 patients in 1998 compared to 4 (4%) of 113 patients in 2008. The mean rate of hydration was significantly higher in 2008 compared with that in 1998 (P = 0.02). In 1998, hydration was provided at 184 mL/h during the first 6 hours and 188 mL/h during the first 12 hours compared with 284 mL/h during the first 6 hours and 221 mL/h during the first 12 hours in 2008. There was a significant decrease in mortality in 2008 compared with that in 1998 (3.5% vs 12%, P = 0.03). CONCLUSIONS The decrease in mortality seen in patients with acute pancreatitis during the last decade may be related to the increased aggressive hydration preventing pancreatic necrosis.
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45
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Abstract
Acute pancreatitis is a common disease most frequently caused by gallstone disease or excess alcohol ingestion. Diagnosis is usually based on characteristic symptoms, often in conjunction with elevated serum pancreatic enzymes. Imaging is not always necessary, but may be performed for many reasons, such as to confirm a diagnosis of pancreatitis, rule out other causes of abdominal pain, elucidate the cause of pancreatitis, or to evaluate for complications such as necrosis or pseudocysts. Though the majority of patients will have mild, self-limiting disease, some will develop severe disease associated with organ failure. These patients are at risk to develop complications from ongoing pancreatic inflammation such as pancreatic necrosis, fluid collections, pseudocysts, and pancreatic duct disruption. Validated scoring systems can help predict the severity of pancreatitis, and thus, guide monitoring and intervention.Treatment of acute pancreatitis involves supportive care with fluid replacement, pain control, and controlled initiation of regular food intake. Prophylactic antibiotics are not recommended in acute pancreatitis if there is no evidence of pancreatic infection. In patients who fail to improve, further evaluation is necessary to assess for complications that require intervention such as pseudocysts or pancreatic necrosis. Endoscopy, including ERCP and EUS, and/or cholecystectomy may be indicated in the appropriate clinical setting. Ultimately, the management of the patient with severe acute pancreatitis will require a multidisciplinary approach.
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Affiliation(s)
- Melissa A Munsell
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.
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46
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Gardner TB, Vege SS, Chari ST, Petersen BT, Topazian MD, Clain JE, Pearson RK, Levy MJ, Sarr MG. Faster rate of initial fluid resuscitation in severe acute pancreatitis diminishes in-hospital mortality. Pancreatology 2010; 9:770-6. [PMID: 20110744 DOI: 10.1159/000210022] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 03/03/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND/AIMS We evaluated the impact of the initial intravenous fluid resuscitation rate within the first 24 h of presentation to the emergency room on important outcomes in severe acute pancreatitis. METHODS Patients presenting directly with a diagnosis of severe acute pancreatitis were identified retrospectively. Patients were divided into two groups - those who received >or=33% ('early resuscitation') and <33% ('late resuscitation') of their cumulative 72-hour intravenous fluid volume within the first 24 h of presentation. The primary clinical outcomes were in-hospital mortality, development of persistent organ failure, and duration of hospitalization. RESULTS 17 patients were identified in the 'early resuscitation' group and 28 in the 'late resuscitation' group and there were no baseline differences in clinical characteristics between groups. Patients in the 'late resuscitation' group experienced greater mortality than those in the 'early resuscitation' group (18 vs. 0%, p < 0.04) and demonstrated a trend toward greater rates of persistent organ failure (43 vs. 35%, p = 0.31). There was no difference in the total amount of fluid given during the first 72 h. CONCLUSIONS Patients with severe acute pancreatitis who do not receive at least one third of their initial 72-hour cumulative intravenous fluid volume during the first 24 h are at risk for greater mortality than those who are initially resuscitated more aggressively.
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Affiliation(s)
- Timothy B Gardner
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic Rochester, Rochester, Minn., USA
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47
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Zerem E, Imamovic G, Omerović S, Imširović B. Randomized controlled trial on sterile fluid collections management in acute pancreatitis: should they be removed? Surg Endosc 2009; 23:2770-2777. [PMID: 19444515 DOI: 10.1007/s00464-009-0487-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2008] [Revised: 02/22/2009] [Accepted: 03/25/2009] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate if percutaneous drainage of sterile fluid collections recurring after initial aspiration in acute pancreatitis yields better results than their conservative management. METHODS Fifty-eight patients with fluid collections in acute pancreatitis were followed up prospectively. Forty of them with sterile fluid collections that recurred after initial aspiration were randomly assigned to two groups of 20 in each. One group was initially treated with conservative management and the other group with prolonged catheter drainage. Patients with unsuccessful initial treatment were converted to more aggressive procedure. Outcome measure was conversion rate to more aggressive procedure. RESULTS Conversion to more aggressive procedure was done in 11 and 3 patients treated conservatively and with catheter drainage, respectively (p = 0.02). Four and 11 patients had bacterial colonization of their fluid collections in conservative management and drainage group, respectively (p = 0.048). Conservative treatment was successful in all six patients with sterile liquid collections < 30 ml. However, this treatment was unsuccessful in all seven patients with multiloculated and liquid collections >100 ml. CONCLUSIONS Prolonged catheter drainage is more efficient for management of recurrent sterile fluid collections in acute pancreatitis than is conservative treatment. Conservative treatment is successful for patients with small fluid collections.
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Affiliation(s)
- Enver Zerem
- The University Clinical Center Tuzla, Trnovac bb, Tuzla, Bosnia and Herzegovina.
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Muddana V, Whitcomb DC, Papachristou GI. Current management and novel insights in acute pancreatitis. Expert Rev Gastroenterol Hepatol 2009; 3:435-44. [PMID: 19673630 DOI: 10.1586/egh.09.27] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute pancreatitis (AP) is a common and potentially lethal acute inflammatory process. Approximately 10-20% of patients develop a severe course and suffer systemic inflammatory response and/or pancreatic necrosis (PNec). To date, there is no single biomarker proven to perform better than clinical judgment in predicting severe AP. The available prognostic clinical scoring systems are used primarily for research purposes. Management of AP is limited to supportive care and treatment of complications when they develop. Patients with mild AP require regular ward admission, fluid administration, bowel rest and pain management. Patients with signs of severe AP should be identified early and admitted promptly to an intensive-care unit. Nutrition support via nasojejunal feedings should be initiated. Sterile PNec is managed conservatively. Infected PNec requires minimally invasive debridement via endoscopic or surgical approaches. The lack of scientific advancements in the management of AP reflects the limited understanding of the early pathogenetic mechanisms and our moderate-to-poor ability to predict severe course at the time of admission.
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Affiliation(s)
- Venkata Muddana
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, PA 15219, USA
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DiMagno MJ, Wamsteker EJ, DeBenedet AT. Advances in managing acute pancreatitis. F1000 MEDICINE REPORTS 2009; 1:59. [PMID: 20539749 PMCID: PMC2881482 DOI: 10.3410/m1-59] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This review highlights advances in acute pancreatitis (AP) made in the past year. We focus on clinical aspects of AP - severe disease especially - and risk stratification tools to guide the clinical care of patients. Most patients with AP have mild disease that requires a diagnostic evaluation, self-limited supportive care, and a short hospital stay. In patients with potentially severe AP, it is important for clinicians to use available risk-stratifying tools to identify high-risk patients and initiate timely interventions such as aggressive fluid resuscitation, close monitoring, early initiation of enteral nutrition, and appropriate use of endoscopic retrograde cholangio-pancreatography. This approach decreases morbidity and possibly mortality and is supported by evidence drawn from recent clinical guidelines, historical literature, and the highest quality studies published in the last year.
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Affiliation(s)
- Matthew J DiMagno
- Department of Internal Medicine, University of Michigan School of Medicine1500 East Medical Center Drive, Ann Arbor, MI 48109USA
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine1500 East Medical Center Drive, Ann Arbor, MI 48109USA
| | - Erik-Jan Wamsteker
- Department of Internal Medicine, University of Michigan School of Medicine1500 East Medical Center Drive, Ann Arbor, MI 48109USA
- Division of Gastroenterology and Hepatology, University of Michigan School of Medicine1500 East Medical Center Drive, Ann Arbor, MI 48109USA
| | - Anthony T DeBenedet
- Department of Internal Medicine, University of Michigan School of Medicine1500 East Medical Center Drive, Ann Arbor, MI 48109USA
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50
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Abstract
Gallstones are the commonest cause of acute pancreatitis (AP), a potentially life-threatening condition, worldwide. The pathogenesis of acute pancreatitis has not been fully understood. Laboratory and radiological investigations are critical for diagnosis as well prognosis prediction. Scoring systems based on radiological findings and serologic inflammatory markers have been proposed as better predictors of disease severity. Early endoscopic retrograde cholangiopancreatography (ERCP) is beneficial in a group of patients with gallstone pancreatitis. Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for acute biliary pancreatitis. The timing of cholecystectomy, following ERCP, for biliary pancreatitis can vary markedly depending on the severity of pancreatitis.
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Affiliation(s)
- Zakaria M. Hazem
- Department of Surgery, College of Medicine, King Faisal University, Dammam, Kingdom of Saudi Arabia,Address for correspondence: Dr. Zakaria M. Hazem, Department of Surgery, King Faisal University, Kingdom of Saudi Arabia, P.O Box 40081, Al-Khobar - 31952. E-mail:
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